Kingsburg Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that care and services were provided in accordance with the manufacturer's instructions for use for an air loss mattress (specialized medical mattress with internal air tubes and tiny holes that continuously circulate air to keep skin dry, cool, and reduce pressure, preventing bedsores (pressure ulcers) by shifting pressure points) and facility staff were trained and competent to use their air loss mattresses safely for one of two sampled residents (Resident (RES)) 2, when RES 2 who had a history of a recent fall (12/9/25) while on an air loss mattress at the facility. RES 2 weighed 124.4 pounds (lbs. -unit of weight measurement) and weight settings on the air loss mattress indicated weight was set at 245 -285 lbs. The nurses assigned to RES 2 did not know what pressure settings should be set on the air loss mattress, and there was no record of any training, education, in-service or competency record for air loss mattress use for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) assessment done quarterly (every three months) as per their written policy and procedure, and failed to initiate elopement risk interventions for Resident 1 when she was assessed to have a significant increase in her elopement risk factors. These failures had the potential to result in Resident 1's elopement from the facility when she was found outside the facility briefly in a confused state early in the winter morning, potentially causing significant risks to Resident 1's health and safety, placing Resident 1 at risk of cold exposure, fear, dehydration and/or other medical complications, or being struck by a motor vehicle. Findings: During a review of Resident 1's admission Record (AR) , dated 1/27/25, the AR indicated she was admitted to the facility during May 2024.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to post the results of the most recent survey document titled Statement Survey Binder in a place readily accessible for 83 of 83 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction. Findings: During an observation on 10/10/24 at 9:31 a.m., a binder titled, State Survey Binder was located in the hallway near the Director of Nursing's (DON) office. During a review of the facility's, State Survey Binder binder, undated, the binder did not contain results for the facilities last recertification survey conducted on 7/14/23. During a concurrent interview and record review on 10/10/24 at 9:07 a.m. with the Administrator (ADM), the facility's State Survey Binder, undated, was reviewed. The State Survey Binder did not contain the results from the facility's last recertification survey on 7/14/24. The ADM stated the last recertification survey's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established State standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full-time; and 2. Ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the Food and Nutrition Services department. The lack of a qualified, full-time, competent supervisor to oversee Food and Nutrition Services, and lack of frequently scheduled consultation from the RD, placed the 83 residents who were admitted to the facility at risk for receiving incorrect food items, not receiving a well-balanced diet that was approved by the RD which could result in residents receiving over or under nutrition that can increase their nutrition risk and further compromise their medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and review of facility documents, the facility failed to ensure the menu was followed: 1. For the lunch meal on October 8, 2024, when steamed spinach was served instead of creamed spinach for 79 of 81 residents eating spinach at the facility. 2. For the lunch meal on October 8, 2024, when an incorrect scoop size was used for the mechanical (diced) ham given to 24 residents (Resident 34, 185, 1, 16, 33, 51, 42, 22, 24, 43, 46, 26, 60, 2, 29, 186, 27, 40, 21, 30, 76, 184, 18, 35) on the dysphagia advanced (Dys Adv per the National Dysphagia Diet as Level 3-food should be: soft solid, easy-to-cut-meats, fruits and vegetables, requires some chewing ability, meats in soft, bite-size pieces) and the 9 residents (Resident 66, 62, 75, 7, 70, 183, 3, 54, 56) on the dysphagia mechanical (Dys Mech per the National Dysphagia Diet as Level 2-food should be: cohesive, moist semi-solid food, requires some chewing ability, ground or minced meats, moist, ground, soft-textured minced or fork-mashable textured foods) diets; 3. For the lunch meal on October 8, 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 21 sampled residents (Residents' 48, 52, and 54) when: 1. Resident 52's oxygen nasal cannula (O2 NC- a tube that directs oxygen into the nose) tubing was observed on top of the oxygen concentrator (medical device that supplies oxygen-enriched air to help people breathe easier) was not stored in a plastic bag. This failure placed Resident 52 at an increased risk to develop respiratory and healthcare associated infections. 2. Resident 48's medication syringe was stored in a wet plastic bag and had some orange liquid substance at the tip of the syringe. This failure placed Resident 48 at an increased risk to develop bacterial infection and gastrointestinal illness. 3. Resident 54 who was on Enhanced Standard/Barrier Precautions (EBP- infection control measures that help reduce the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for three of six sampled residents (Residents' 3, 13 and 64) when: 1. Resident 3 was administered escitalopram oxalate tablet (medication used to treat depression [serious mental illness affecting person's though, feelings, behavior, and sense of well-being] from 6/2/24-6/31/24, 7/1/24-7/31/24 and 81/24-8/27/24 and informed consent was not obtained prior to medication administration. 2. Resident 13 was administered sertraline HCl tablet (medication used to treat depression) from 8/1/24 to 10/14/24 and informed consent was not obtained prior to medication administration. 3. Resident 64 was administered buspirone HCl tablet (medication used to treat anxiety [feeling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for two of eight sampled residents (Resident 75 and Resident 29) when: 1. Resident 75 did not have a care plan (a document that outlines how a resident's health care needs will be met, and is used by the resident and their care team to facilitate communication and collaboration) for the use of indwelling urinary catheter (thin, flexible tube inserted into the bladder through the urethra to drain urine). This failure placed Resident 75 at risk for her indwelling urinary catheter needs to not be met. 2. Resident 29 did not have a care plan for urinary tract infection (UTI- common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract). This failure had the potential to result in Resident 29's care needs to go unmet. Findings: 1. During a concurrent observation and interview on 10/8/24 at 10:13 a.m. in Resident 75's room, Resident 75…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two of eight sampled residents (Resident 29 and Resident 55) when: 1. License nurses continued to sign the physician's order to monitor for side effects for Resident 29's anticoagulant medication which was discontinued on 9/5/24. This failure resulted in an inaccurate documentation and monitoring of Resident 29's medical symptoms related to the side effects if a medication that has been discontinued. 2. Licensed Vocational Nurse (LVN) 1 prepared and signed Resident 55's medications, and the Infection Preventionist (IP) administered the medication prepared by LVN 1. This failure had the potential for Resident 55 to not received the medication and could lead to medication error and or drug diversion. Findings: 1. During a review of Resident's admission Record (AR-a document with personal identifiable and medical information), dated 10/10/24 the AR indicated, Resident 29 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide personal hygiene for two of eight sampled residents (Resident 233 and 32) when Resident 233 and 32's fingernails were long and had black particles underneath. This failure had the potential to result in Resident 233 and 32 to develop skin infections or sustain skin injuries. Findings: During a concurrent observation and interview on 10/8/24 at 8:37 a.m. in Resident 233's room, Resident 233 had long fingernails with black particles underneath. Resident 233 stated, he did not like his fingernails long and wanted them cleaned and cut. Resident 233 stated he did not remember the last time his fingernails were cut. During an interview on 10/8/24 at 8:44 a.m. with the Director of Staff Development (DSD), the DSD stated, Certified Nursing Assistant (CNA) 8 should have cleaned resident's fingernail daily. The DSD stated nurses were responsible cutting diabetic (a chronic disease that occurs when the body doesn't produce or use insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of three sampled Residents (Resident 13 and Resident 33) received the necessary care and respiratory services, consistent with professional standards of practice when: 1. Resident 13's oxygen (a colorless, odorless, tasteless gas essential to living organisms) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order (an order given for specific patient/resident by a health care provider). This failure resulted in Resident 13 not obtaining the ordered amount of oxygen via the oxygen concentrator (a machine that pulls in the air around you), which could lead to breathing problems which includes shortness of breath, headache, and confusion. 2. Resident 33's oxygen flow rate was given at a lower rate than the physician's order (a set of written or verbal instructions from a doctor that clinicians follow to care for a patient). This failure had the potential for Resident 33 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 48 and 133) were assessed for the use of bed (side rails) when Residents 48 and 133 had no assessment for the risk of entrapment, a physician's order specifying reason for use was not obtained and a care plan was not created. Additionally Resident 133 did not have informed consent obtained (a form signed by the resident or family explaining the risks). This failure had the potential to place Resident 48 and 133 at risk for decreased freedom of movement, entrapment and/or injury. Findings: During a review of Resident 48's Minimum Data Set (MDS- a resident assessment too used to identify cognitive (mental process) and physical functional level assessment, dated 9/22/2024, indicated Resident 48's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 00 out of 15 indicating Resident 48 has severe cognitive impairment (0-7 indicated severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (6.9 % [percent]) when: 1. Licensed Vocational Nurse (LVN)1 did not administer Resident 48's metformin (brand name-medication used to control high blood sugar) medication during medication pass. This failure had the potential to result in a high blood sugar which could lead to serious medical condition. 2. Resident 23 had a lidocaine patch (transdermal[through the skin] skin patch- topical anesthetic that numbs pain by blocking the nerve signals in your skin) and in place for more than 12 hours. This failure resulted in Resident 23 receiving more than the recommended dose and had the potential for adverse side effects. Findings: 1. During a concurrent observation and interview on 10/10/24 at 8:24 a.m. in Station 2, LVN prepared Resident 48's medications and administered six of seven medications scheduled for Resident 48. LVN stated she did not administer metformin to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards of practice for three of 14 sampled residents (Residents 18, 51, and 76) when: 1a. Resident 51's Fluticasone Propionate (medication sprayed into the nostrils in order to reduce swelling in the body) was not labeled with its expiration date. 1b. Resident 76's albuterol sulfate (medication used to help open up the airways making it easier to breathe) was not labeled with its expiration date. These failures placed Residents 51 and 76 at risk of being administered medications way past its expiration date which could result in less effective medications. 2. Resident 18's insulin pen (pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge) was missing a label on the pen. This failure had the potential to result for Resident 18 at risk of receiving an incorrect medication. 3. Four medication pills were found on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and review of facility documents, the facility failed to: 1. Ensure Resident food preferences were accommodated for three residents (Resident 44, 75, 184); and 2. Provide an alternate option when residents disliked a food group for two residents (Resident 31, 39). This failure had the potential to increase residents' refusal of food items due to the facility not following the resident's preferences and potential reduction of meeting the resident's nutritional needs. 3. Resident 52 's dislike of warm food and preference of cold food on his meal ticket (document used to write a resident ' s diet, likes, dislikes, and allergies) was not documented. This failure had the potential for Resident 52 to not receive the caloric intake needed to meet his nutritional needs. Findings: 1. During the lunch meal observation on 10/08/24 at 12:00 PM, in the kitchen, the steam table contained the following food items: Hawaiian baked ham, steamed spinach, mashed sweet potatoes, poppyseed roll. During a review of the facility document titled, hcsg1NewGen2024 Diet Guide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety when the sanitizer solution was not the appropriate concentration to sanitize food preparation areas and equipment. This failure had the potential to result in cross contamination and the growth of microorganisms which could lead to food borne illness for the 83 residents admitted to the facility. Findings: During an observation in the kitchen on 10/08/24 at 3:36 PM, Food Service Worker (FSW) 1 wiped down a food service cart with a rag from the red bucket sanitation solution. The red bucket sanitation solution concentration was tested with a dip test strip result zero parts per million (ppm). During a concurrent interview at the same time with FSW 1, FSW 1 stated the concentration of the red bucket sanitation solution should be 200 ppm. The sanitation solution in the red bucket was dumped in the sink, replaced, and re-tested with a dip test strip result of 200 ppm. During an observation in the kitchen on 10/08/24 at 4:41 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of four sampled residents (Resident 39) when: 1. Licensed Vocational Nurse (LVN) 1 checked Resident 39's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. 2. LVN 1 administered medication to Resident 39 and did not provide privacy. These failures resulted in Resident 39 not being provided with respect and dignity while his B/P was checked and while taking his medication. Findings: 1. During an observation on 10/10/24 at 7:38 a.m. in Station 2 in Resident 39's room, Resident 39 was sitting up in bed watching TV and appropriately dressed. LVN 1 approached Resident 39's bedside and checked Resident 39's blood pressure without closing the privacy curtain or the door, while staff, residents and visitors walked by. During an interview on 10/10/24 at 10:10 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of one of five sampled residents (Resident 75) when Resident 75's diagnosis of indwelling urinary catheter was not coded on the MDS assessment. This failure had the potential to result in Resident 75's care needs to not be met. Findings: During a concurrent observation and interview on 10/8/24 at 10:15 a.m. in Resident 75's room, Resident 75 was laying in bed with eyes open, urinary catheter was observed hanged on the side of the bed with yellow urine. Resident 75 stated she needed the catheter because she was not able to void. Resident 75 stated she prefers to stay in bed. During a review of Resident 75's admission Record (document with resident demographic and medical diagnosis information), dated 10/11/24, indicated Resident 75 was admitted in the facility on 10/11/24 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of 8 sampled resident (Resident 29) when the care plan was not updated to reflect the insulin (a hormone that regulates blood sugar levels by moving glucose from the bloodstream into cells throughout the body) medication was discontinued on 7/23/24. This failure had the potential for Resident 29's care needs to go unmet. Findings: During a review of Resident's admission Record (AR-a document with personal identifiable and medical information), dated 10/10/24 the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (disease in which your blood glucose, or blood sugar, levels are too high), hypertension (high blood pressure- is when the pressure in your blood vessels is too high (140/90 mmHg or higher) end stage renal disease, (ESRD- is a medical condition in which a person's kidneys cease functioning on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet residents needs for one of four sampled residents (Resident 48) when Resident 48's metformin (brand name-medication used to control high blood sugar) medication was not available for administration for two days (10/9/24 and 10/10/24). This failure had the potential for Resident 48's blood sugar to increase which could result to serious medical condition. Findings: During a concurrent observation and interview on 8/10/24 at 8/:24 a.m. in Resident 48's room, Resident 48 was sitting up in bed watching TV, Resident 48 was appropriately dressed and stated he was happy in the facility. During a concurrent observation and interview on 8/10/24 at 8:30 a.m. in Station 2 hallway, Licensed Vocational Nurse (LVN) 1 was observed preparing Resident 48's medications. LVN 1 did not administer Resident 48's metformin. LVN 1 stated she did not administer the medication because it was not available. LVN 1 stated licensed nurse are responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility documents, the facility failed to ensure support personnel was able to effectively carry out the functions of food and nutrition services when [NAME] 1 did not follow menus and recipes. This failure resulted in not accommodating resident preferences which could result in disinterest in meals and decreased meal intake which has a potential to result in weight loss which can compromise the medical condition. This also had the potential to result in increased residents' risk of choking for nine residents. Findings: 1. a. During the review of facility document titled, hcsg1NewGen 2024 Diet Guide Sheet for 10/8/24, showed ½ cup of creamed spinach for the following diets: Regular, Dys Adv, Dys Mech, renal, vegetarian. It showed for the puree diet to serve pureed creamed spinach. During a lunch meal observation on 10/08/24 starting at 12:00 PM, in the kitchen, [NAME] 1 prepared the tray line steam table with: puree (steamed) spinach, regular (steamed) spinach. During an interview with [NAME] 1 on 10/8/24 at 12:48 PM, [NAME] 1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of facility documents, the facility failed to ensure pureed food was in the proper form when a whole green bean was served on a pureed diet test tray. This failure had the potential to increase the risk of choking for nine residents who had physician ordered pureed diets due to having severe chewing and/or swallowing problems. Findings: During a lunch meal observation in the kitchen on 10/09/24 at 12:26 PM, meals were placed on trays and put into food cart 4. A regular and puree test tray was ordered by the surveyors. [NAME] 1 plated the test tray for the puree diet test tray with pureed ravioli, pureed bread, pureed salad. During an observation on 10/09/24, at 12:48 PM, food cart 4 arrived at nursing station 2 and the test trays were sampled in the hallway, in conjunction with the Certified Dietary Manager (CDM) 1. A whole green bean was identified in the pureed salad. A concurrent interview was conducted at this time with the CDM 1, he acknowledged the whole green bean in the puree salad and stated that was not okay. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure physician prescribed diets were followed for one of seven sampled residents (Resident 6) when Resident 6 did not receive his ordered double portion meal for lunch on 10/8/24. This failure placed Resident 6 at risk to not receive the full nutritional value of his meal which had the potential for Resident 6 to experience weight loss Findings: During a review of Residents 6's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 10/10/24, the AR indicated Resident 6's admitting diagnoses included the following: sepsis (a serious condition in which the body responds improperly to an infection), gangrene (a serious condition that occurs when tissue in the body dies due to a lack of blood flow), acquired absence of left below knee (surgical removal of the leg). During an observation on 10/08/24 at 1:03 p.m. in the dining room, Resident 6 was served a regular portion for his lunch. During a review of Resident 6's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility documents, the facility failed to provide a comfortable environment in the kitchen for staff. This failure had the potential to increase staff risk of developing heat related illnesses such as heat cramps, heat exhaustion or heatstroke caused by exposure to heat. Findings: During an observation on 10/8/24 at 12:44 PM in the kitchen, the surveyor thermometer read 89.4 degrees Fahrenheit (F) near the hand wash sink. During an observation on 10/8/24 at 3:28 PM in the kitchen, the surveyor thermometer placed on the counter in the center of the kitchen read 90.1 degrees F. During an interview on 10/8/24 at 3:34 PM in the kitchen, [NAME] 2 stated the kitchen is usually this warm. Surveyor thermometer placed on the counter in the center of the kitchen read 90.7 degrees F. During an observation on 10/8/24 at 4:51 PM in the kitchen, the surveyor thermometer placed on the counter in the center of the kitchen read 93.6 degrees F. During an interview with Certified Dietary Manager (CDM) 1 on 10/9/24 at 10:52 AM, CDM 1 stated the air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to create a care plan for elopement (to run away secretively) risk for one of three sampled residents (Resident 1) when Resident 1 attempted to leave against medical advice (AMA) from an appointment at the dialysis center on 8/23/23 and was assessed to be a risk for elopement. This failure resulted in Resident 1 successfully leaving AMA from the dialysis center on 9/6/23. FINDINGS: During an interview on 9/13/23 at 8:35 a.m. with Social Service Director (SSD), SSD stated she was aware Resident 1 had eloped from previous Skilled Nursing Facilities (SNF) but she had never eloped from current SNF. SSD stated she did not know if Resident 1 had a care plan for Elopement. During a concurrent interview and record review on 9/13/23 at 8:48 am with Licensed Vocational Nurse (LVN) 1, Patient 1's care plans, nurses notes dated 8/23/23, and elopement evaluations dated 8/10/23 and 8/23/24 were reviewed. LVN 1 stated Resident 1 often talked about how she wanted to get out of this place . LVN 1 read the nurses note from 8/23/23 by LVN 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. There was no air gap (a fixture that provides back-flow prevention) underneath the food prep sink and the two-compartment sink. 2. Three silver-colored pitchers had grime and build up inside. 3.There were Saltine crackers and graham crackers past the use by date. 4. A package of hot dog buns and a package of sliced bread did not have labels identifying the open dates and use by dates. 5. A container of applesauce did not have the use by date. 6. The freezer temperature reading was 12 °F (degrees fahrenheit [scale of temperature]). These failures had the potential to result in foodborne illnesses (illness caused by consuming contaminated food) from the growth of microorganisms for the 80 residents eating food prepared in the facility's kitchen. Findings: 1. During a concurrent observation and interview on 7/10/23 at 9:11 a.m. in the kitchen, the two-compartment sink had no air gap with the piping be routed into the wall. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain kitchen equipment in safe operating condition when the steamer machine in the kitchen was leaking and dripping liquid onto towels placed under the equipment. This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner which could affect the residents health. Findings: During a concurrent observation and interview on 7/10/23, at 9:03 a.m., in the kitchen, the steamer machine was leaking from the front bottom right and left corners onto two white towels which were lined with a brown substance. The Certified Dietary Manager (CDM) stated, the towels were placed under the steamer machine to catch the dripping water. During an interview on 7/12/23, at 2:49 p.m., with CDM, CDM stated, the steamer machine in the kitchen was dripping onto towels which caused the towels to be lined with a brown substance. CDM stated, kitchen equipment should have been kept functioning properly to facilitate food preparation for the residents. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for two of six sampled residents (Resident 11 and Resident 56) when: 1. Resident 11 was administered lorazepam (medication used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) without current and updated informed consent. 2. Resident 56 was administered escitalopram (brand name) and trazodone (medications used to treat depression [mood disorder characterized by feelings of sadness and loss of interest]) on 6/27/23 to 7/11/23 and informed consent was not obtained prior to medication administration. These failures resulted in Resident 11 and Resident 56 to be administered with psychotropic medications and not fully…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for 3 of 12 residents (Residents 2, 26 and 66) when: 1. Resident 66's care plan reflected active interventions for treatment to his right foot even after having a right below the knee amputation (surgical removal of limb). This failure placed Resident 66 at a potential risk of his right lower leg care needs not to be met. 2. Resident 12 no longer used a communication board (paper with words and pictures) to communicate with staff. This failure placed Resident 12 at a potential risk of not being able to communicate her needs due to not having a tool to help communicate. 3. Resident 26's care plan reflected ongoing physical therapy, occupational therapy and speech therapy (therapies to help improve one's mobility, activities of daily living and speaking services). This failure placed Resident 26 at a potential risk for his current care needs not to be met. Findings: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet professional standards of practice for 4 of 12 sampled residents (Residents 22, 28, 47 and 22 ) when: 1. Licensed Vocational Nurse (LVN) 6 failed to follow the manufacturers direction to shake tube feeding formula prior to hanging and administering to Resident 22. This failure placed Resident 22 at a potential risk to not receiving the amount of nutrition ordered by the physician. 2. LVN 6 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 22's medications. This failure resulted in inaccurate charting and placed Resident 22 at a risk to not receive the medication ordered. 3. LVN 11 did not follow medication administration direction when she gave medication to Resident 47 without giving food. This failure had the potential to put Resident 47 at risk for stomach upset. 4. A small medication cup filled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. One Fluticasone Prop 50mcg (microgram -a unit of measure) spray (medication used to treat allergy) was opened with no label of used-by date or open date and another bottle of Fluticasone was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 138 and Resident 69. 2. Resident 81's Ipratropium/Albuterol (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath) medication was expired. This failure had the potential to decrease the medication potency that could compromise the therapeutic effectiveness when used by Resident 81. 3. Resident 22's Insulin Lispro (medication used to treat diabetes[high blood sugar]) was opened with no indication of used-by date or when the insulin was opened. This failure had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly for three out of four dumpsters when the dumpster lids were not have securely closed lids. This failure had the potential to attract rodents, insects and flies and spread infection which placed residents at risk for foodborne illness. Findings: During a concurrent observation and interview on 7/10/23 at 1:58 p.m. with Certified Dietary Manager (CDM), in the back parking lot of the facility, there were four dumpsters. One dumpster had a lid which was fully open. A second dumpster had a lid that was propped open due to trash piled up underneath the lid. A third dumpster had two lids that were ill-fitting which created a gap between the lids. CDM stated, the lids to the three dumpsters were not closed securely. CDM stated staff were to keep the lids completely closed after opening. CDM stated, bugs and rodents could have entered the dumpsters with the lids open. During a concurrent observation and interview on 7/13/23 at 9:00 a.m. with Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete, accurately documented in accordance with accepted professional standards of practice for eight of 38 residents (Residents 22, 26, 29, 32, 55, 59, 66 and 73) when: Residents 22, 26, 29, 32, 55, 59, 66 and 73's Physician Order for Life Sustaining Treatment (POLST- a document indicating wishes for end-of-life care) were incomplete in the residents medical record. This failure had the potential risk for Residents' 22, 26, 29, 32, 55, 56, 59, 66 and 73's end-of-life care decisions to not be followed in case of an emergency. Findings: 1. During a review of Resident 22's admission Record (AR), undated, the AR indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care (specialized care for people with a serious illness), chronic obstructive pulmonary disease (group of diseases which causes blocked airflow and difficulty breathing), hemiplegia (paralysis on one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for three of 12 sampled residents (Residents 4 and 22, and 33) when: 1. Resident 4's room entry did not have signage indicating he was on Enhanced Barrier Precautions (EBP- gown and glove use during high contact resident care activities, designed to reduce transmission MDROs [organisms resistant to multiple antibiotics]) or indicate what precautions and personal protective equipment (PPE-items worn to protect healthcare worker from body fluids and infectious diseases) were required. This failure had the potential to infect staff, residents and other visitors with Methicillin Resistant Staphylococcus Aureus (MRSA- a bacteria which is difficult to treat due to resistance to antibiotics) and spread it to others. 2. Resident 22's gastrostomy tube (G-tube -tube inserted through the abdominal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 2) when Registered Nurse (RN) left her workstation computer open and unattended with resident information exposed to public view. This failure resulted in violation of Resident 2's rights to confidentiality and the potential for unauthorized access to Resident 2's personal information. Findings: During a concurrent observation and interview on 7/11/23, at 7:05 am., in station 1 hallway, a medication cart was parked outside of room [ROOM NUMBER], the computer on the medication cart was left open and unattended by RN. The computer screen displayed Residents 2's name, photo, room number, allergies and a list of prescribed medications visible to everyone who passed by the medication cart out in the hallway. During a review of Resident 2's admission Record (AR- document which contain patient personal information), dated 7/13/23, the AR indicated Resident 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 11) when Resident 11's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 11's care needs not met. Findings: During a review of Resident 11's admission Record (document with resident demographic and medical diagnosis information), dated 7/12/23, indicated Resident was admitted in the facility on 12/22/22 with diagnoses which included unspecified psychosis (mental health problem that causes people to perceive or interpret things differently from those around them) and anxiety (feeling of fear, dread, and uneasiness). During a review of Resident 11's, Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 56) when Resident 56 was on continuous oxygen (a life supporting component of air) therapy for her respiratory illness. This failure placed Resident 56 at a potential risk for her oxygen care needs not met. Findings: During a concurrent observation and interview on 7/10/23, at 8:35 a.m., with Resident 56's room, Resident 56 was sitting up in bed watching television. Resident 56 was on oxygen via nasal cannula (small flexible tube to deliver supplemental oxygen) connected to an oxygen concentrator (medical device that produces oxygen) at bedside. Resident 56 stated the oxygen helped her breathing. During a review of Resident 56's admission Record (AR-a document with personal identifiable and medical information), dated 7/12/23, the AR indicated, Resident 59 was admitted on [DATE] with diagnoses which included sepsis (body's extreme response to an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide proper maintenance and care for residents with foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) for one of two sampled residents (Resident 65) when Resident 65's urinary catheter bag was touching the floor on three separate occasions. This failure resulted in compromised urine drainage and accumulation of a large amount of sediment in the urinary catheter tubing and placed Resident 65 at a potential risk for catheter contamination, urinary retention (unable to empty the bladder) and a urinary tract infection (UTI-an infection in any part of the urinary system [kidneys, ureters, bladder]). Findings: During an observation on 7/12/23, at 3:30 p.m., Resident 65 was lying in bed resting. Resident 65's bed was in the lowest position and the foley catheter bag hanging on the bed frame, folded in half and touching the floor. Resident 65's catheter tubing was filled with cloudy,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of six sampled residents (Resident 35) when Resident 35's Benazepril (brand name [medication used to treat high blood pressure]) was not available for administration for 8 days (7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23 and 7/11/23). This failure had the potential for Resident 35's blood pressure to be uncontrolled and lead to serious medical condition. Findings: During a concurrent medication pass observation and interview on 7/11/23 at 7:15 a.m., at Station 1, RN was preparing Resident 35's medications after checking blood pressure which was 168/93. RN did not administer Resident 35's benazepril medication. RN stated the medication was not available to give to Resident 35. RN stated Resident 35's B/P was at 168/93 and could go higher. RN stated having high blood pressure could result to a more serious health condition because the medication was not administered. RN stated follow-up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (eight percent) when: 1. Registered Nurse (RN) did not administer Resident 35's benazepril (brand name [medication used to treat high blood pressure]) medication during medication pass. This failure had the potential for Resident 35's blood pressure to go higher and lead to serious medical condition. 2. RN administered diltiazem (medication used to treat high blood pressure) medication to Resident 68 with blood pressure of 157/71 and pulse rate of 51. This failure resulted in Resident 68 receiving her blood pressure medication not as prescribed by the physician and had the potential for Resident 68's blood pressure and pulse to go lower and lead to serious medical condition. Findings: 1. During a concurrent observation and interview on 7/11/23 at 7:15 a.m., in Station 1, RN was passing medication. RN checked Resident 35's blood pressure which was noted as 168/93. RN prepared Resident 35's medications and administered two of three medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the planned menu was followed for one of 81 residents (Resident 83) when incorrect portion sizes of the spinach au gratin and baked sweet potatoes was served to Resident 83 during lunch on 7/11/23. This failure had the potential for Resident 83 to receive the wrong caloric intake and not meet his nutritional needs. Findings: During a concurrent observation and interview on 7/11/23, at 12:55 p.m., in the kitchen, Assistant Supervisor (AS) served a gray scoop (4 oz.[ounce - unit of measure]/ 1/2 cup) of spinach au gratin, a gray scoop of baked sweet potatoes to a large portion meal. AS stated, the large portion tray received same sized gray scoops of the spinach au gratin and baked sweet potatoes as a regular tray. During a concurrent interview and record review on 7/12/23, at 2:55 p.m., the Tuesday (Day 24) Lunch Diet Guide Sheet, dated 5/8/23, was reviewed. The Diet Guide Sheet indicated, the large meal was to receive 2/3 cup of Spinach Au Gratin and 2/3 cup of Baked Sweet Potatoes. The Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed ensure their policy and procedure was followed for one of five sampled residents (Resident 29) when there was no documentation of Resident 29's education of the risk and benefits and his refusal of the Influenza vaccine (a preparation used to stimulate body's immune response against infection by flu viruses). This failure had the potential for Resident 29 of not being informed on the risks and benefits of receiving the influenza vaccine and not being able to make an informed decision. Findings: During a review of Resident 29's admission Record (AR-a document with personal identifiable and medical information), undated, the AR indicated, Resident 29 was admitted to the facility on [DATE] and Resident 29 was [AGE] years old. During concurrent interview and record review on 7/14/23 at 2:37 p.m. with the Infection Preventionist (IP), Resident 29's medical record for Influenza Immunization Informed consent forms was reviewed. The IP stated Resident 29 refused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.